Upper gastrointestinal bleeding following transcatheter aortic valve replacement: A retrospective analysis

Stanger, Dylan; Abdulla, Alym; Wong, Fabian; Alipour, Sina; Bressler, Brian; Wood, David; Webb, John G.

doi:10.1002/ccd.26650

Cited by 16 publications

(12 citation statements)

References 23 publications

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“…Our analysis indicates that treatment with TT or SAC is associated with adverse clinical outcomes compared to treatment with AP alone after TAVR, which is consistent with findings from other studies of patients undergoing TAVR [ 17 , 18 ] and surgical aortic valve replacement [ 19 ]. We did not observe a benefit on ischemic endpoints with regimens using 2 or 3 antithrombotics compared to AP alone, as rates of MI and stroke were similar among the three treatment groups, but the study was not powered to do so.…”

Section: Discussionsupporting

confidence: 91%

Impact of Antithrombotic Regimen on Mortality, Ischemic, and Bleeding Outcomes after Transcatheter Aortic Valve Replacement

et al. 2018

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IntroductionOptimal antithrombotic therapy after transcatheter aortic valve replacement (TAVR) remains unclear. We evaluated the association between antithrombotic regimens and outcomes in TAVR patients.MethodsWe retrospectively analyzed consecutive patients who underwent TAVR at a single academic center from April 2009 to March 2014. Antithrombotic regimens were classified as single or dual antiplatelet therapy (AP), single antiplatelet plus anticoagulant (SAC), or triple therapy (TT). The primary endpoint was a composite of death, myocardial infarction (MI), stroke, and major bleeding. Adjusted hazard ratios (HRs) were obtained with best subset variable selection methods using bootstrap resampling.ResultsOf 246 patients who underwent TAVR, 241 were eligible for analysis with 133, 88, and 20 patients in the AP, SAC, and TT groups, respectively. During a median 2.1-year follow-up, 53.5% had at least one endpoint—the most common was death (68%), followed by major bleeding (23%), stroke (6%), and MI (3%). At 2 years, the composite outcome occurred in 70% of TT, 42% of SAC, and 31% of AP patients. Compared to AP, adjusted HRs for the composite outcome were 2.88 [95% Confidence intervals (CI) (1.61–5.16); p = 0.0004] and 1.66 (95% CI [1.13-2.42]; p = 0.009) in the TT and SAC groups, respectively. Mortality rates at 2 years were 61% in the TT, 32% in the SAC, and 26% in the AP groups (p = 0.005).ConclusionsThe risk of the composite outcome of death, MI, stroke, or major bleeding at 2-year follow-up was significantly higher in TAVR patients treated with TT or SAC versus AP, even after multivariate adjustment.

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Section: Discussionsupporting

confidence: 91%

Impact of Antithrombotic Regimen on Mortality, Ischemic, and Bleeding Outcomes after Transcatheter Aortic Valve Replacement

et al. 2018

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“…The overall rate of both upper and lower GIB bleeding was 1.4% in our cohort. Similarly, a study on 841 patients undergoing TAVR reported an incidence of 2% for upper GIB in the immediate post TAVR period [10]. For comparison, the rate of GIB within 30 days and after 30 days of TAVR have were reported to be 2.41% and 5.4%, respectively (7,8) The most common culprit lesion found during endoscopy in our cohort was angiodysplasia occurring in 0.6% of patients.…”

Section: Discussionsupporting

confidence: 58%

“…Some studies have reported that patients on postprocedural triple antithrombotic therapy were at the highest risk for severe upper GIB. More specifically, these patients were found to be at a >10-fold higher risk of upper GIB when compared to patients not on triple antithrombotic therapy [10].…”

Section: Discussionmentioning

confidence: 92%

Factors Associated with Gastrointestinal Bleeding During Hospitalization for Transcatheter Aortic Valve Replacement: A Retrospective Cohort Study

Spiewak

Eskandari

Wang

et al. 2019

Preprint

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Background & Aims Gastrointestinal bleeding (GIB) is the most common bleeding complication post transcatheter aortic valve replacement (TAVR). Yet, the literature is sparse and incomplete. This study aims to identify the incidence and risk factors for GIB immediately following TAVR. Methods A retrospective study was performed among 489 patients who were hospitalized for TAVR at UC Davis Medical Center from (January 1, 2012 to June 30, 2017). The incidence of both upper and lower GIB, and potential risk factors during the same hospitalization were reviewed. Univariate analysis was done to identify independent risk factors. Results Mean age was 81.6 years and 49% were male, 23% had CKD3 or worse, 34% had history of prior GIB. Mean baseline Hgb and platelet count were 12.0 g/dl and 197000/ml, respectively. Dual antiplatelet therapy and anticoagulation were used in 396 (81%) and 155 (32%) patients, respectively. Gastric prophylaxis with either PPIs or H2 receptor blockers was used in 336 (69%). Incidence of GIB was 1.4% (7/489) with 5 cases of upper GIB, 1 small intestinal GIB and 1 lower GIB. The most common culprit lesion found during endoscopy was angiodysplasia (3/5) and successful endoscopic intervention was performed. On univariate regression analysis, only a low hemoglobin level on admission was associated with increased likelihood of GIB (OR=1.49, p=0.051 per 1 g/dl decrease). Conclusions GIB is rare immediately post-TAVR. Angiodysplasia was the most common etiology in our series. Baseline anemia is a predictor of GIB in this setting.

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“…Stanger et al in a single center retrospective evaluation showed that TAVR is associated with a moderate risk of severe UGIB. Patients on triple antithrombotic therapy are at highest risk for severe UGIB [32]…”

Section: Discussionmentioning

confidence: 99%

Diagnosis and Management of Rare Case of Mesenteric Hematoma Rupture after Transcatheter Aortic Valve Replacement (TAVR): A Case Report and Review of the Literature

Abbasi

Vanhook

Salartash

et al. 2018

Case Reports in Vascular Medicine

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We present a case of a 78-year-old female with history of diastolic heart failure and paroxysmal atrial fibrillation on apixaban presenting with worsening shortness of breath. She underwent transesophageal echocardiogram showing severe aortic stenosis with a valve area of 0.8 cm2. Coronary angiography did not reveal significant coronary artery disease. CT of chest, abdomen, and pelvis did not show any evidence of hematoma or dissection. Patient was scheduled for transfemoral TAVR. Patient's apixaban was discontinued prior to the procedure. She received heparin during the procedure. She successfully underwent left transfemoral aortic valve replacement. Shortly after the procedure, she complained of abdominal pain and became hypotensive. Blood pressure was 76/44 mm of Hg (MAP 58). Hemoglobin dropped to 8.1 g/dl (baseline 13). Stat CT abdomen and pelvis showed a large volume of hemorrhage in the peritoneal cavity. CTA of abdomen showed no evidence of aortic aneurysm or dissection but active extravasation below the inferior aspect of the spleen. Catheterization of the superior mesenteric artery (SMA) identified ileal branch of SMA as the source of bleeding. Embolization using gel foam slurry followed by a coil insertion was performed. Repeat angiogram demonstrated continued extravasation through arcade collaterals. A rapid exploration of the abdominal cavity revealed ruptured mesenteric hematoma. Evacuation of hematoma was performed. Portion of small ileum and bleeding mesenteric branch vessel was resected. Her condition stabilized with no postoperative bleeding and she was discharged on warfarin postoperatively. Use of antithrombotic therapy increases risk of bleeding in TAVR patients. Mesenteric hematoma rupture if not identified can be life-threatening. We believe that this is the first reported case of mesenteric hematoma rupture after a TAVR procedure.

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Upper gastrointestinal bleeding following transcatheter aortic valve replacement: A retrospective analysis

Abstract: This large cohort study demonstrates that TAVR is associated with a moderate risk of severe UGIB. The results of this study suggest that patients on triple antithrombotic therapy are at highest risk for severe UGIB. © 2016 Wiley Periodicals, Inc.

Cited by 16 publications

References 23 publications

Impact of Antithrombotic Regimen on Mortality, Ischemic, and Bleeding Outcomes after Transcatheter Aortic Valve Replacement

Impact of Antithrombotic Regimen on Mortality, Ischemic, and Bleeding Outcomes after Transcatheter Aortic Valve Replacement

Factors Associated with Gastrointestinal Bleeding During Hospitalization for Transcatheter Aortic Valve Replacement: A Retrospective Cohort Study

Diagnosis and Management of Rare Case of Mesenteric Hematoma Rupture after Transcatheter Aortic Valve Replacement (TAVR): A Case Report and Review of the Literature

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